=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649720699
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAYLOR REGIONAL MEDICAL GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2016
-----------------------------------------------------
Last Update Date | 07/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 KINGSWOOD DR
-----------------------------------------------------
City | CAMPBELLSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42718-9634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-789-1112
-----------------------------------------------------
Fax | 270-789-6176
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1698 OLD LEBANON RD
-----------------------------------------------------
City | CAMPBELLSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42718-9662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-789-6087
-----------------------------------------------------
Fax | 270-789-6119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COORDINATOR
-----------------------------------------------------
Name | DEBRA ANN WALDRON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-465-3561
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------